A Grassroots Approach to Treating Social Determinants of Health

On December 5th, Becky Wilkinson, MSW, CWSA and Regional Behavioral Health Outreach Program Manager at Providence Health presented a Collective-sponsored webinar through Inside Digital Health on addressing social determinants of health (SDOH). She shared details of a multi-faceted outreach program focusing on at-risk patients in clinics, emergency departments (EDs), and other care settings.

The Program

The Providence Better Outcomes thru Bridges (BOB) program focuses on helping the community’s most vulnerable patients—with the goal of empowering individuals by meeting them where they are (both figuratively and literally), helping them create goals, and ultimately allowing the patient to guide their own care. Becky shared how this trauma-informed care can help redefine the meaning of success for each individual.

Becky went on to discuss Providence’s rural health clinic outpatient program, which started about a year ago. Providence now has an outreach team based out of internal and family medicine that screens every patient with Medicare and Medicaid for SDOH. Eligible patients are offered navigation assistance for needs like food, transportation, and housing.

In addition to clinic outreach, the BOB program also focuses on ED-specific outreach for patients with either six ED visits in six weeks or 20 visits in 12 months, and a diagnosed behavioral health condition. Patients who meet this criteria are then referred to the ED-specific multidisciplinary team that meets monthly to discuss the needs of the most vulnerable patients and create care plans to help them.

Homelessness

A key part of the BOB program is helping homeless patients—38 percent of BOB clients have identified as homeless or facing imminent homelessness. The BOB team had been able to connect 25 percent of those clients to stable housing, but they wanted to do more. Becky shared how the team started looking for additional ways to help more patients get into housing and detailed two partnerships allowing Providence to achieve that goal.

In 2018, the BOB team met with the Metropolitan Alliance for Common Good (MACG) Clackamas housing team, which wanted to introduce safe overnight shelter options to the area, but lacked the necessary case management resources to do so. Providence and MACG were able to partner together to introduce overnight shelter options on various properties in and around the county. They worked with landowners, businesses, churches, and other organizations to secure space for overnight parking or tiny huts. Becky shared that these smaller, scattered shelter models have proven to be successful because they can easily be moved or modified as needed.

Another project focused on homelessness is the Agape Village partnership, where a village of 15 tiny homes have just finished being built behind a local church. Becky expressed her excitement for the completion of this project and explained that the BOB team gets to use two of the homes for patients leaving the ED in exchange for case management and on-site peer support services. The BOB team is hoping to start placing patients in tiny homes later this month.

BOB Program Outcomes

Becky discussed that these small, community-driven solutions might not solve everything, but make a big difference to the people who are able to get off the streets. She shared a heartwarming story about “Kevin,” who was in need of housing but was struggling due to chronic pain, a substance use disorder, and a felony on his record. Kevin is now living in an apartment and working full-time at a nonprofit thanks to the help of the BOB team, combined with his determination to overcome barriers.

Yet, the impact of the efforts made by Providence Health and the BOB team have been noticed in the community, and beyond. Around 42 percent of BOB clients have shown a 50 percent reduction in ED utilization. But most importantly, patients are getting the care they need, and individuals are getting off the street and back on their feet.

To learn more about Providence Health’s BOB program, you can view the webinar here.